Navigated Unicompartmental Knee Arthroplasty: A Different Perspective

Rajesh Malhotra,Saurabh Gupta,Vivek Gupta,Vikrant Manhas 대한정형외과학회 2021 Clinics in Orthopedic Surgery Vol.13 No.4

Background: Anteromedial osteoarthritis is a recognized indication for unicompartmental knee arthroplasty (UKA). Favorable postoperative outcomes largely depend on proper patient selection, correct implant positioning, and limb alignment. Computer navigation has a proven value over conventional systems in reducing mechanical errors in total knee arthroplasty (TKA). However, the lack of strong evidence impedes the universal use of computer navigation technology in UKA. Therefore, this study was proposed to investigate the accuracy of component positioning and limb alignment in computer navigated UKA and to observe the role of navigation in proper patient selection. Methods: A total of 50 knees (38 patients) underwent computer navigated UKA between 2016 and 2018. All operations were performed by the senior surgeon using the same navigation system and implant type. The navigation system was used as a tool to aid patient selection: knees with preoperative residual varus > 5° on valgus stress and hyperextension > 10° were switched to navigated TKA. We measured the accuracy of component placement in sagittal and coronal planes on postoperative radiographs. Functional outcomes were also evaluated at the final follow-up (a minimum of 16 months). Results: Nine patients had tibia vara and 14 patients had preoperative hyperextension deformity. We observed coronal outliers for the tibial component in 12% knees and for the femoral component in 10% knees. We also observed sagittal outliers for the tibial component in 14% knees and for the femoral component in 6% knees. There was a significant improvement in the functional score at the final follow-up. On multiple linear regression, no difference was found in functional scores of knees with or without tibia vara (p = 0.16) and with or without hyperextension (p = 0.25). Conclusions: Our study further validates the role of computer navigation in desirable implant positioning and limb alignment. We encourage use of computer-assisted navigation as a tool for patient selection, as it allows intraoperative dynamic goniometry and provides real-time kinematic behavior of the knee to obviate pitfalls such as significant residual varus angulation and hyperextension that predispose early failure of UKA.

Risk Factors and Outcomes Associated with Intraoperative Fractures during Short-Stem Total Hip Arthroplasty for Osteonecrosis of the Femoral Head

Rajesh Malhotra,Saurabh Gupta,Vivek Gupta,Vikrant Manhas 대한정형외과학회 2022 Clinics in Orthopedic Surgery Vol.14 No.1

Background: Young age in osteonecrosis of the femoral head (ONFH) demands bone-preserving, short-stem arthroplasty. Several designs including neck-preserving stems and neck-resecting, shortened, standard stems are classified as short stems. There is a paucity of literature investigating risk factors and outcomes of intraoperative complications of neck preserving, short-stem arthroplasty in ONFH. Methods: A total of 107 hips operated with METHA short-stem arthroplasty for ONFH were retrospectively evaluated. The mean age of patients was 43.7 years (range, 27–60 years). Nine patients had an intraoperative fracture. Seven hips received prophylactic cerclage wiring for poor bone quality. Patients were invited for clinical and radiological evaluation at the latest follow-up. Results: The mean follow-up of patients was 47.2 months. Significant association with intraoperative fractures and the need for prophylactic cerclage wiring were found in steroids-, alcohol-, and chronic renal failure-induced ONFH. However, patient sex, body mass index, traumatic/idiopathic ONFH, previous implant in situ , prosthesis size, and single-sitting bilateral total hip replacement (THA) were not the risk factors. All hips showed signs of osteointegration at final follow-up. No revision was done during the study period for any cause. Conclusions: METHA short-stem THA offers excellent functional and radiological outcomes in ONFH. However, precaution must be exercised in patients with steroids-, alcohol-, and renal disorders-induced ONFN due to poor bone quality and higher chances of intraoperative fractures. Also, additional measures such as the use of a high-speed burr and prophylactic cerclage wiring in ONFH may allow predictable and safe use of short stems.

Cup-Cage Construct Using Porous Cup with Burch-Schneider Cage in the Management of Complex Acetabular Fractures

( Rajesh Malhotra ),( Deepak Gautam ) 대한고관절학회 2019 Hip and Pelvis Vol.31 No.2

Purpose: Cup-cage construct technique was developed to address the massive acetabular defects during revision hip arthroplasty. Indications have extended to complex acetabular fractures with pelvic discontinuity necessitating acute total hip arthroplasty. However, its use is constrained in low socioeconomic countries due to non-availability of the original cages from Trabecular Metal Acetabular Revision System and high cost. We used a novel technique using the less expensive Burch-Schneider (BS) cage and Trabecular Metal Revision Shell (TMRS) to address the problem. Materials and Methods: We reviewed a consecutive series of 8 cases of acetabular fractures reconstructed using a ‘cup-cage construct’ technique using a BS cage along with a TMRS. The mean age of the patients was 61.4 years. Patients were followed up for a mean period of 50.5 months (24 to 72 months). The patients were assessed clinically with Harris Hip Score and radiologically with serial X-rays. Results: All the patients were available at the latest follow up. The mean Harris Hip Score was 87.2. There was no radiological evidence of failure. One patient had dislocation two months following the surgery, which was treated by closed reduction and hip abduction brace. One patient developed an infection at 3 weeks necessitating debridement. The same patient had sciatic nerve palsy that recovered after 4 months. Conclusion: This novel technique of the cup-cage construct seems to provide a stable construct at short to midterm follow-up. However, a long-term follow up would be required.

A Randomized Controlled Study to Compare the Total and Hidden Blood Loss in Computer-Assisted Surgery and Conventional Surgical Technique of Total Knee Replacement

Amit Singla,Rajesh Malhotra,Vijay Kumar,Chandra Lekha,G. Karthikeyan,Vishwas Malik 대한정형외과학회 2015 Clinics in Orthopedic Surgery Vol.7 No.2

Background: Total knee arthroplasty (TKA) is associated with considerable blood loss. Computer-assisted surgery (CAS) is different from conventional TKA as it avoids opening the intramedullary canal. Hence, CAS should be associated with less blood loss. Methods: Fifty-seven patients were randomized into two groups of CAS and conventional TKA. In conventional group intramedullary femoral and extramedullary tibial jigs were used whereas in CAS group imageless navigation system was used. All surgeries were done under tourniquet. Total and hidden blood loss was calculated in both groups and compared. Results: The mean total blood loss was 980 mL in conventional group and 970 mL in CAS group with median of 1,067 mL (range, 59 to 1,791 mL) in conventional group and 863 mL (range, 111 to 2,032 mL) in CAS group. There was no significant difference in total blood loss between the two groups (p = 0.811). We have found significant hidden blood loss in both techniques, which is 54.8% of the total loss in the conventional technique and 59.5% in the computer-assisted navigation technique. Conclusions: There is no significant difference in total and hidden blood loss in the TKA in CAS and conventional TKA. However, there is significant hidden blood loss in both techniques. There was no relation of tourniquet time with blood loss.

Utility of 16S rRNA PCR in the Synovial Fluid for the Diagnosis of Prosthetic Joint Infection

Sujeesh Sebastian,Rajesh Malhotra,Vishnubhatla Sreenivas,Arti Kapil,Rama Chaudhry,Benu Dhawan 대한진단검사의학회 2018 Annals of Laboratory Medicine Vol.38 No.6

Conventional culture has been the mainstay for diagnosing prosthetic joint infections (PJIs), with synovial fluid and periprosthetic tissue samples being the preferred sample types [1]. However, culture-based methods often give false-negative results in patients with a high likelihood of PJI [2]. To overcome the limitations of culture methods, molecular techniques like universal 16S rRNA gene and pathogen-specific PCRs were developed for PJI diagnosis [2, 3]. Although PCR assays have shown satisfactory results in tests of periprosthetic tissue samples and sonication fluid, the diagnostic utility of PCR is less clear in tests of the synovial fluid [2-4]. Most studies that evaluated the utility of 16S rRNA PCR in the synovial fluid for diagnosing PJI have not used the Musculoskeletal Infection Society (MSIS) consensus criteria as the gold standard for PJI [2, 5]. Therefore, we evaluated the utility of 16S rRNA PCR in the synovial fluid for diagnosing PJI using MSIS criteria.

Medial Ball and Socket Total Knee Arthroplasty in Indian Population: 5-Year Clinical Results

Sahil Batra,Rajesh Malhotra 대한정형외과학회 2022 Clinics in Orthopedic Surgery Vol.14 No.1

Background: Medial pivot total knee arthroplasty aims to restore native knee kinematics through highly conforming medial tibiofemoral articulation with survival comparable to contemporary knee designs. The aim of this study was to report preliminary clinical results of medial pivot total knee arthroplasty in an Indian population. Methods: A retrospective analysis of 45 patients (average age, 62 years; 40 women and 5 men) with end-stage arthritis (Kellgren- Lawrence grade 4) operated with a medial pivot prosthesis was done. All patients were assessed using Knee Society Score (satisfaction, expectation, and functional scores) and Oxford Knee Score, and range of motion was recorded at the end of 5-year postoperative follow-up. In addition, all patients underwent standardized radiological assessment. Results: At the final follow-up, patients reported significant improvement in mean Knee Society Score (satisfaction, expectation, and functional scores) and Oxford Knee Score (p < 0.05). The mean range of motion achieved at the end of 5 years ranged from 0° (extension) to 118.4° (further flexion). There was no evidence of loosening or osteolysis at a minimum follow-up of 5 years. Conclusions: These results demonstrated satisfactory clinical and radiological outcomes at 5 years after total knee arthroplasty with a medial pivot design, which may be related to better replication of natural knee kinematics with the medial pivot knee and inherent advantages of this design.

Injury Mechanisms of Hip Fractures in India

( Jaiben George ),( Vijay Sharma ),( Kamran Farooque ),( Samarth Mittal ),( Vivek Trikha ),( Rajesh Malhotra ) 대한고관절학회 2021 Hip and Pelvis Vol.33 No.2

Purpose: Hip fractures are a major cause of morbidity and mortality in the elderly; however, the current literature on the injury patterns of hip fractures in India is lacking. Understanding the injury profile of these patients is important to develop targeted interventions to prevent hip fractures. Materials and Methods: This was a prospective study of all hip fracture patients aged 50 years or older admitted from February 2019 to December 2019. Details about the injury were recorded by an in-person interview. Multivariate logistic regression analysis was used to identify the factors associated with any particular injury mechanism. Results: Two hundred and eighty-three hip fractures were included. The mechanism of injury for the majority of patients was a fall from a standing height (n=217, 76.7%) while 60 patients (21.2%) were injured as the result of a road traffic accident (RTA). Slipping on a wet floor (n=49, 22.6%) and change in posture (n=35, 16.1%) were the most commonly reported reasons for falling. Pedestrian injuries were the most common form of RTA (n=29, 48.3%). Increasing age (P<0.001) and female sex (P=0.001) were associated with fall as the mode of injury while sustaining another fracture in addition to hip fracture (P=0.032) was associated with RTA as the mode of injury. Conclusion: A fall from standing height is the predominant mode of injury among elderly hip fractures especially among women. Environmental hazards and postural changes are responsible for the majority of falls while pedestrian accidents contribute to a majority of the RTAs.

The Impact of Surgical Timing of Hip Fracture on Mortality: Do the Cause and Duration of Delay Matter?

Jaiben George,Vijay Sharma,Kamran Farooque,Samarth Mittal,Vivek Trikha,Rajesh Malhotra 대한고관절학회 2023 Hip and Pelvis Vol.35 No.3

Purpose: Delay in performance of hip fracture surgery can be caused by medical and/or administrative reasons. Although early surgery is recommended, it is unclear what constitutes a delayed surgery and whether the impact of delayed surgery can differ depending on the reason for the delay. Materials and Methods: A total of 269 consecutive hip fracture patients over 50 years of age who underwent surgery were prospectively enrolled. They were divided into two groups: early and delayed (time from reaching the hospital to surgery less than or more than 48 hours). Patients were also categorized as fit or unfit based on anesthetic fitness. One-year mortality was recorded, and regression analyses were performed to assess the impact of delay on mortality. Results: A total of 153 patients (56.9%) had delayed surgery with a mean time to surgery of 87±70 hours. A total of 115 patients (42.8%) were considered medically fit to undergo surgery. No difference in one-year mortality was observed between patients with early surgery and those with delayed surgery (P=0.854). However, when assessment of the time to surgery was performed in a continuous manner, mortality increased with prolonged time to surgery, particularly in unfit patients, and higher mortality was observed when the delay exceeded six days (fit: P=0.117; unfit: P=0.035). Conclusion: The effect of delay on mortality was predominantly observed in patients who were not considered medically fit, suggesting that surgical delays might have a greater impact on patients with medical reasons for delay.

Single-stage long-stem total knee arthroplasty in severe arthritis with stress fracture: a systematic review

( Shubhankar Shekhar ),( Alok Rai ),( Saket Prakash ),( Tarun Khare ),( Rajesh Malhotra ) 대한슬관절학회 2023 대한슬관절학회지 Vol.35 No.-

Purpose Proximal tibia stress fractures present a challenge when performing total knee arthroplasty (TKA) in knee arthritis (KA). The literature on treatment modalities for stress fractures with arthritis is varied and not systematically reviewed. We aimed to answer the questions: (1) Is long-stem TKA sufficient for stress fractures in arthritic knees? (2) Should stress fracture and KA be addressed simultaneously? (3) What is the role of augmentative procedures in stress fractures with knee arthritis? (4) Can a unified algorithm be established? Methods The PubMed and Cochrane databases were searched for keywords such as stress fracture, knee arthritis and total knee arthroplasty, published from January 1995 to 29 May 2022. A total of 472 records were screened down to 13 articles on the basis of our selection criteria. Ten data items were recorded from the included studies. The methodological index for non-randomised studies (MINORS) score for the included studies was 17 ± 3. Results We found long-stem TKA to be sufficient for most cases and advocated for single-stage treatment of stress fractures and arthritis. Augmentative procedures play a role in the treatment, and a unified algorithm was drafted to guide treatment. Conclusion Single-stage management of advanced KA with a stress fracture causes less morbidity than a staged procedure. Long-stem TKA, with or without an augmentative procedure, is an excellent option.

Single-stage long-stem total knee arthroplasty in severe arthritis with stress fracture: a systematic review

( Shubhankar Shekhar ),( Alok Rai¸ Saket Prakash ),( Tarun Khare ),( Rajesh Malhotra ) 대한슬관절학회 2023 대한슬관절학회지 Vol.35 No.-

Purpose Proximal tibia stress fractures present a challenge when performing total knee arthroplasty (TKA) in knee arthritis (KA). The literature on treatment modalities for stress fractures with arthritis is varied and not systematically reviewed. We aimed to answer the questions: (1) Is long-stem TKA sufficient for stress fractures in arthritic knees? (2) Should stress fracture and KA be addressed simultaneously? (3) What is the role of augmentative procedures in stress fractures with knee arthritis? (4) Can a unified algorithm be established? Methods The PubMed and Cochrane databases were searched for keywords such as stress fracture, knee arthritis and total knee arthroplasty, published from January 1995 to 29 May 2022. A total of 472 records were screened down to 13 articles on the basis of our selection criteria. Ten data items were recorded from the included studies. The methodological index for non-randomised studies (MINORS) score for the included studies was 17 ± 3. Results We found long-stem TKA to be sufficient for most cases and advocated for single-stage treatment of stress fractures and arthritis. Augmentative procedures play a role in the treatment, and a unified algorithm was drafted to guide treatment. Conclusion Single-stage management of advanced KA with a stress fracture causes less morbidity than a staged procedure. Long-stem TKA, with or without an augmentative procedure, is an excellent option.